First, do nothing

Short White Coat is a blog about learning to be a doctor. Posts appear here as part of White Coat Notes. Ishani Ganguli is a third-year Harvard medical student. E-mail her at shortwhitecoat@gmail.com.

If surgeons are cowboys, then tending to the ranch has become just as central to their mission as riding off into the often unknown terrain of human anatomy. By the end of our three-month surgery rotation, this was a resounding theme: In the art and science of surgical decision-making, sometimes it’s better to wait.

Take the appendix, an evolutionary remnant that surgeons have been slicing out for nearly 125 years, whether it’s inflamed or merely encountered during another operation. Once the diagnosis of appendicitis is confirmed, it’s best to go right to the operating room to remove the organ before it bursts, we learned. But if the initial window of action has passed, and the disease process has produced a local collection of pus or a severely inflamed appendix, it’s often better to drain the site and wait 8 to 10 weeks to let the inflammation cool down before operating.

The so-called interval appendectomy emerged from the finding that the sickest patients don’t do well under the knife. In this case, such conservative management is a luxury that’s been afforded by better antibiotics and supported by clinical evidence.

Whether it’s a blood vessel malformation in the brain, a potentially cancerous skin discoloration, or a slow growing prostate tumor -- the latest teaching is often to watch and wait. In some ways, it seems a fitting counter to increasingly aggressive imaging and screening practices that can pick up symptomless diagnoses better off unmade. Ultimately, for patients, weighing the risks and benefits of surgery can be as much psychological as it is somatic -- are they willing to live with a growth or an organ that’s doing them little good?

And so, here’s a slight modification of the Hippocratic oath for surgeons: First, do nothing. But if and when cutting becomes the best option, giddy up.